Those with mental illness are more likely to be victims of crime than perpetrators. But, in Maine, when they do commit serious crimes, they are often sent to Riverview Psychiatric Center in Augusta as forensic patients. How Riverview manages their treatment is one of the major challenges facing the state hospital, which just lost more than half its budget for failing to meet federal standards for care. Even some within Riverview say the hospital is at a crossroads.

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Mental Blocks Part 5: Riverview

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Andy Bilyeu spent years working in mental health services. He was a crisis worker and, at one time, managed a group home. He says he never thought he would need treatment at a psychiatric hospital. But currently, he's one of about 50 forensic patients at Riverview. These are patients who are referred through the Criminal Justice System.

"So my charges are criminal threatening with a dangerous weapon and assault to an officer."

It happened five years ago, when Bilyeu went to a hospital for a medical emergency. He didn't think he was being seen quickly enough, and when a doctor finally entered the room, Bilyeu raised a scalpel.

"And I said, 'Are you going to treat me?' And my intention was not to harm the physician, it was more sitting there and weighing my options and hurting myself."

The incident landed Bilyeu in jail, and he was eventually admitted to Riverview. Like most others who arrive at the state psychiatric hospital, it was not his choice.

"My view was - I'm here, now how do I get out the door, I have years of experience working in this system. These people are telling me all kinds of things that are uncomfortable and I believe are not true."

But after two years of treatment, Bilyeu was discharged...for the first time.

"Riverview subscribes to a model more or less on sustained compliance, and if you're able to demonstrate that, you're allowed to get out of here."

Sustained compliance means following the rules. Another forensic patient at Riverview - Don Beauchene describes it this way:

"They have a policy here - no borrowing, no lending, no giving, no sharing."

Beauchene says these rules are for safety, but they're not helpful for social interraction or for forming healthy relationships. And patients aren't the only ones who challenge Riverview's approach to treatment.

"My name is J Harper, and I'm a Patient Advocate at Riverview Psychiatric Center. I work for the Disability Rights Center."

Harper's job is to ensure patient rights aren't compromised. He says rather than focus on a control the hospital should emphasize recovery. It's a model where the patient has a strong voice in their treatment. Where staff ask questions like:

"What can I do for you, what do you think would help? How is it going today? Instead of saying, 'Here's the diagnosis, and we have three, four, five medications that will help you deal with trying to tone down the voices you're telling me about'. And the common effect of all of those is they're sedating. They're not helping the person deal with the fact they have these voices. They're helping the person sleep through voice or ignore the voice chemically."

Harper says there is a role for both models, but Riverview needs to decide which is its primary philosophy. The failure to do that, he says, is why the hospital has recently lost 20 million dollars, more than half its budget. The federal government pulled the funding after inspections revealed serious deficiencies, including the use of tasers to subdue some forensic patients.

"It's all about safety, that's the bottom line."

Mary Louise McEwen is superintendent of Riverview. She says most of Riverview's 92 beds used to be taken up by patients who were civilly committed, a legal process in which patients are ordered into treatment . But a couple years ago, demand shifted and now two-thirds of the beds are forensic, meaning most patients come from the criminal justice system for being declared incompetent to stand trial, not criminaly responsible, or in need of evaulation or treatment.

"And we made some of the decisions we made based on the population that we were being referred, that were court ordered to come here, that we have no say. That other psychiatric hospitals would be able to say, sorry, we can't manage that person - they have a history of assaultiveness or dangerousness. "

J Harper agrees that Riverview has seen more complex cases in recent years. Patients are coming in with brain injuries and dementia. But after working at the hospital for eight years, Harper wonders:

"How come for six years I never had the tasers and we got by? How come it is now that I have the tasers, and now I have more documented instances of aggressive behavior by clients?"

Ensuring safety, says Harper, comes down to providing effective therapy, which will vary from patient to patient, but for him the correct approach should be recovery first. Mary Louise McEwen says Riverview is committed to that model.

"I think we do some recovery aspects really well, but we need to see how can we continue to focus on recovery with the challenging population that we're dealing with now."

It's that model that Andy Bilyeu says made a difference for him. When he was readmitted to Riverview in 2011 for violating the terms of his discharge, he lobbied to receive a unique style of therapy. Bilyeu says, with the help of clinical staff, the treatment gave him insight into his past criminal behavior and substance abuse. He's diagnosed with bipolar and dissociative disorder and says he realized he drank to mask the pain from childhoood trauma. Now, Bilyeu says, he knows how to manage himself...and in September, a court agreed. He was granted an order to be discharged from Riverview to a supervised apartment. But he's still waiting for a spot to open up.

"The idea that was going to happen was kind of a pipe dream, because there's such a backlog of people here. There's one woman in front of me waiting for a supervised apartment, and she's had a court order since the end of July, and she's still here."

On any given day there are at least three to four patients waiting for discharge into supported living, and another ten to twelve waiting to be admitted to a bed at riverview, that costs about a thousand dollars per day.